Medicare Compliance & Reimbursement

Find out before it's too late if your auditor knows the score

Myth: Any coder can perform a chart audit.

Reality: Your auditor should be someone who understands the clinical scenarios your physicians are dealing with. An auditor should also be aware that different carriers may use different audit tools.

Your coder or biller should have a good working knowledge of Medicare's documentation and coding guidelines, especially for evaluation and management visits, says Catherine Brink, president of Healthcare Resource Inc., in Spring Lake, NJ.

An auditor also needs to know the difference between the 1995 and 1997 E/M guidelines, and understand the ins and outs of common procedures in your office, says Brink.

Coding staff often believe that "there is only one way to audit and that only the auditor's criteria are correct," says Ron Nelson, president of Health Services Associates in Fremont, MI. In fact, there are many different audit tools, and the auditor isn't always right.

This is especially true when the auditor doesn't understand clinical issues, says Nelson. If the auditor has not spent time using the documentation criteria from the clinician's perspective, then the result could lead to inappropriate upcoding or downcoding.

When it comes to E/M visits, your auditor should always use the tool your local carrier has identified as appropriate, says Suzan Hvizdash, physician educator with the UPMC Dept. of Surgery in Pittsburgh. That way, you'll be sure your auditor is auditing the same documentation and using the same tool structure as the carrier.

Note: Some carriers mix the 1995 and 1997 E/M documentation guidelines, she points out.

For surgeries, the auditor should be knowledgeable about the procedure and be able to interpret the operative report, says Brink. The auditor should have "a good working knowledge" of auditing both E/M and surgery claims, she says.

Your auditor should also know how to compile the audit's results and how to educate providers if needed, says Brink.

Tip: Physicians should use audit results as a tool and shouldn't accept the recommendations of an audit without reviewing them personally, says Nelson.